Physician non-compliance with clinical practice guidelines remains a critical barrier to high quality care. Serious games using gaming technology for serious purposes have emerged as a method of studying physician decision making. However, little is known about their validity.

Methods

We created a serious game and evaluated its construct validity. We used the decision context of trauma triage in the Emergency Department of non-trauma centers, given widely accepted guidelines that recommend the transfer of severely injured patients to trauma centers. We designed cases with the premise that the representativeness heuristic influences triage i.e. physicians make transfer decisions based on archetypes of severely injured patients rather than guidelines. We randomized a convenience sample of emergency medicine physicians to a control or cognitive load arm, and compared performance disposition decisions, number of orders entered, time spent per case. We hypothesized that cognitive load would increase the use of heuristics, increasing the transfer of representative cases and decreasing the transfer of non-representative cases.

Findings

We recruited 209 physicians, of whom 168 79% began and 142 68% completed the task. Physicians transferred 31% of severely injured patients during the game, consistent with rates of transfer for severely injured patients in practice. They entered the same average number of orders in both arms control C: 10.9 SD 4.8 vs. cognitive load CL:10.7 SD 5.6, p = 0.74, despite spending less time per case in the control arm C: 9.7 SD 7.1 vs. CL: 11.7 SD 6.7 minutes, p<0.01. Physicians were equally likely to transfer representative cases in the two arms C: 45% vs. CL: 34%, p = 0.20, but were more likely to transfer non-representative cases in the control arm C: 38% vs. CL: 26%, p = 0.03.

Conclusions

We found that physicians made decisions consistent with actual practice, that we could manipulate cognitive load, and that load increased the use of heuristics, as predicted by cognitive theory.